Isolated Ileum Perforation Following Veal Attack in a Pacient with an Undiagnosed Inguinal Hernia: Case Report and Review of the Literature.

We present a rare case of a 74 year old man admitted by ambulance to our department following a blunt minor abdominal trauma (veal attack). He complained of pain in the left abdominal flank and in the lower abdomen. The lower abdomen was tender, moderate distended but not rigid. He also had a left inguinal uncomplicated hernia. Because he was hemodynamic stable we performed a CT - scan who revealed several pockets of free air anteriorly in the midline. One hour and a half after admission the pacient underwent exploratory laparotomy, revealing a antimesostenic perforation of the ileum about 120 cm from the ileo-cecal valve. Simple closure in one layer was performed. The inguinal hernia wasn't repaired at the time of the first surgery. The postoperative course was favorable, the pacient being discharged on the 8th postoperative day.

High Grade Penetrating Pancreatic Trauma - Case Report and Review of the Literature.

INTRODUCTION: The pancreatic injuries have fortunately a low frequency, but when present associate multiple intraabdominal lesions, and carry a significant morbidity and mortality. The aim of this study is to underline the significant morbidity associated with high grade pancreatic injuries. CASE REPORT: Female patient, 36 years old, with penetrating abdominal trauma due to domestic violence was referred to our center from a regional county hospital, after multiple laparotomies, hemodynamically unstable, with multiple organ failure. Abdominal clinical exam revealed evisceration, with massive pancreatic leakage at the level of the median laparotomy and through the stabbing wounds from the right flank. Emergency Computed Tomography showed multiple intraabdominal collections, with laceration of the liver, right kidney and pancreatic head. Abdominal exploration was decided. After a thorough abdominal debridement was revealed a deep laceration of the pancreatic head, with active extravasation of pancreatic secretion, correlating with a grade IV injury. Peritoneal lavage and large drainage of the lesser and greater peritoneal cavity was performed. The postoperative recovery was uneventful, with progressive decrease in pancreatic fistula output and discharge after 35 days. CONCLUSIONS: High grade pancreatic traumas associate a significant morbidity. Efficient drainage of the pancreatic head injuries and patients management in high volume centers for pancreatic surgery maximize the survival rate.

Traumatic Tricuspid Valve Rupture after Blunt Chest Trauma - A Case Report and Review of the Literature.

INTRODUCTION: Despite the high frequency of thoracic injuries secondary to traffic related accidents, the blunt cardiac valve rupture is extremely rare. METHOD: Case report and review of the literature using PubMed/MEDLINE and EMBASE databases. RESULT: A 38 year old female patient, victim of car accident was admitted. On primary survey the patient was conscious, cooperative and hemodynamic and respiratory stable. On secondary survey was found a bilateral open leg fracture and a seat belt sign. Whole body Computed Tomography revealed minimal haemorrhagic contusion of the cortex, left hemopneumothorax and right pneumothorax, bilateral rib fractures, liver contusion, left femoral neck fracture and fracture to the lumbar spinal column. After bilateral pleurostomy, the patient becomes hemodynamically unstable, but with no signs of external bleeding. The transthoracic echocardiography revealed an acute severe tricuspid regurgitation with hepatic veins reflux. After orthopaedic surgeries, the tricuspid valve rupture was managed by replacing the valve with a bioprostheses. The hospital stay was 122 days. CONCLUSION: Only a high index of suspicion may reveal blunt cardiac lesions as a cause for hemodynamic instability in acute setting.

Bleeding gastric cancer in young and elderly patients.

PURPOSE: This study tried to find the differences between gastric cancer in young and elderly, in addition through the importance of the presence of the upper gastrointestinal bleeding, with two examples of clinical cases. METHODS: Two groups of patients divided by age were compared. The first group consisted of 13 cases of patients aged between 32 and 41, and the second consisted of 15 cases, aged 80 to 87 years. The variables considered were: sex, personal history and family history, onset-admission interval, number of days of hospitalization after surgery, the number of days until discharge, personal history/ family history, tumor location, admission diagnosis, intervention type, value hemoglobin on admission, the way externalizing hemorrhage appeared, stage, tumor type/ degree of differentiation of its kind lymph dissection, postoperative complications and deaths. RESULTS: The interval from symptom onset to hospital admission was higher in young people with a greater weight loss and malignant ulcer history or upload family were smokers, but apparently with a lower complication rate. In the elderly, the anemic syndrome was the main event and the complications were more related to comorbidities. CONCLUSIONS: Prolonged gastric distress in young patients, associated with smoking, personal history of ulcer and family history of neoplasia should guide the diagnosis to gastric cancer. Anemic syndrome in the elderly may be due to the gastric cancer, and complications are due to comorbidities.

Hematochezia due to Caecal Angiodysplazia led to Diagnosis of a Transverse Colon Cancer in a Young Female Patient: Case Report and Literature Review.

We present an unusual case of a caecal angiodysplasia whose bleeding determined the discovery of a mid-transverse colon cancer in a 26 years old female patient. After the initial successful angiographic treatment of the caecal lesion the patient underwent laparoscopic - assisted transverse colectomy. The postoperative evolution was favorable, without resumption of bleeding episodes and rapid social reintegration. The histopathology revealed mucinous adenocarcinoma that penetrates the visceral serous with 7 lymph nodes invasion of 18 examined. As a result of the advanced stage, pT4aN2bM0 - stage IIIC, the life expectancy at 5 years is between 30 to 50%.

Can the Principles of Oncological Surgery be Complied with in Haemorrhagic Gastric Cancer?

AIM: To discover if in the case of bleeding gastric cancer the principles of oncological surgery could be applied to gastric cancer. METHODS: We studied two groups of patients, one with haemorrhagic gastric cancer and the second with uncomplicated gastric cancer. We took into account gender, age, number of days from admission to surgery, tumour location, type of intervention,haemoglobin on admission, haemorrhage externalization pathway, comorbidities, intervention type, extension of lymphadenectomy, stage, tumour type degree of differentiation there of, number of excised lymph nodes, perineural and vascular invasion, preoperative transfusion, postoperative complications, deaths. RESULTS: The rate of postoperative complications is higher for patients in group 1 who presented upper gastrointestinal bleeding, an increase in the number of days of hospitalization and care, with a higher risk of surgical re-intervention and a higher mortality for these patients. CONCLUSIONS: in the case of haemorrhagic gastric cancer surgery,we can apply the principles of malignant stomach cancer surgery, but with a higher rate of postoperative complications,more hospitalization days and higher mortality.

Massive intraoperative bleeding after laparoscopic assisted abdominoperineal resection: a case report and systematic review of the literature.

INTRODUCTION: The laparoscopic-assisted abdominoperineal resection (LAPR) has been proved to be associated with a shorter postoperative recovery, with equivalent oncological results and similar survival when compared with conventional open surgery, for patients with low rectal cancer. METHOD: Case report of a massive intraoperative bleeding during LAPR and systematic review of the English language literature, using PubMed Medline, ISI Thopmson, OVID and EMBASE databases. RESULTS: 58 years old patient admitted in emergency setting or rectal bleeding. Rectal examination revealed a protruding,frail tumor, located 2 cm from the anal verge. Total colono scopy revealed an infiltrative, protruding tumor, situated at 2 cm from the anal verge, with a 5 cm cranial extension,without any additional colonic lesions. Computed Tomography showed a 4,5 cm circumferential rectal wall thickening, without any enlarged mesorectal or abdominal lymph nodes. The patient was transported to operating room for a LAPR. During final hemostasis, at the level of perineal surgical wound, an acute massive bleeding occurred from the presacral vessels with severe blood loss. This bleeding couldnot be managed laparo scopicaly and conversion to laparotomywas decided, with pelvic packing. At 48 hours after the initial surgical approach, the tamponing packs were removed, without signs of active bleeding. There were applied haemostatic agents and the perineal wound was sutured, without further rbleeding during in-hospital stay. CONCLUSIONS: A rapid and effective control of the presacral bleeding is mandatory to prevent a fatal outcome. Pelvic packing remains a life-saving procedure and the treatment of choice in severe cases.

Epidemiology of diverticular disease -- systematic review of the literature.

INTRODUCTION: Associated with the Western diet and life style,diverticular disease is affecting more and more developing countries worldwide. Recent studies show an increase in incidence of the disease at young age, that raises the risk of complications, along with major consequences for the patient but also for the healthcare system. METHOD: Systematic review of the literature with US National Library of Medicine and National Institutes of Health International PubMed Medline, using abstracts and articles available in PubMed Medline, Cochrane databases searching for ("Diverticulosis, Colonic epidemiology" [MeSH] OR"Diverticulosis, Colonic etiology" [MeSH] OR "Diverticulosis,Colonic genetics" [MeSH] OR "Diverticulosis, Colonic history" [MeSH]). RESULTS: Even from the rise of diverticular disease as a public healthcare problem, at the end of the previous century, it was associated with a diet rich in refined sugars, lacking vegetable fibres. The higher incidence in countries like U.S.A., Canada, United Kingdom and the northern states compared with its rare occurrence in the sub-Saharan African continent, strengthen the anterior assumptions. In regions like Asia, the disease pattern is characterized by are latively low incidence of colonic diverticular disease, with distribution of diverticula mainly on the right colon. The different incidence by sex and age show the possible existence of hormonal protective factors. Studies from countries with a rich ethnic diversity, bring into question the probable genetic predisposition to diverticular disease, fact backed-up by the few studies on twins and 1st degree relatives available in the literature. DISCUSSION: The rising incidence of colonic diverticular disease in Romania makes our country adhere the epidemiologic model existing in countries with a close socio-economic status.Although with a lower incidence than countries that have adopted a Western diet, Romania is likely to encounter a public health problem, if certain measures to identify and minimise the population exposure to risk factors are not taken.

The role of angiography and embolization in blunt splenic trauma.

The spleen is one of the most vulnerable organs in the event of an abdominal trauma. Preservation of the spleen and of course its functions has been a continuing challenge familiar not only for trauma surgeons but also for all those for whom the integrity of this organ was a well-founded goal. Therefore nonoperative management (NOM) of spleen trauma injury has faced a continuous development, gradually becoming an option of healing by first intention among Trauma Centers. Through the development of modern technology it has become possible to keep observation documents on the evolution of blunt splenic injuries and, also, minimally invasive therapeutic approach has become possible. Out of these approaches angiography and consecutive embolization are gaining more and more ground considering the increasing experience and the convincing results that have been constantly reported in the last few years.

Thoracoscopic left splanchnicectomy - role in pain control in unresectable pancreatic cancer. Initial experience.

BACKGROUND: The management of opiate-dependent intractable abdominal pain caused by unresectable pancreatic cancer remains challenging. The aim of this study was to evaluate the safety and efficacy of thoracoscopic unilateral left splanchnicectomy for pain control in a first series of 15 patients with unresectable pancreatic cancer. PATIENTS AND METHODS: Fifteen patients suffering from intractable pain due to unresectable pancreatic cancer (stage III and IV)underwent thoracoscopic unilateral left splanchnicectomy. To assess pain severity and the impact of this palliative procedure for pain relief, all patients completed Wong-Baker Faces Pain Rating Scale with a preoperative pain degree between 7 and 9. RESULTS: Surgical intervention duration varied from 30 minutes to 1 hour. Pleural drainage tube was removed 24 hours postoperatively.There were no complications nor deaths.Immediate pain relief (pain degree 0-2) was achieved in all patients after thoracoscopic unilateral splanchnicectomy, same level being registered at first check-up after one month. CONCLUSIONS: Thoracoscopic unilateral left splanchnicectomy decreases the pain substantially and significantly improves the quality of life in patients with unresectable pancreatic cancer.

Trauma registry -- a necessity of modern clinical practice.

INTRODUCTION: Traumas represent the cause of 10 % of deaths in the entire world. The successful development of trauma systems, including the use of trauma registries, played a significant part in lowering the mortality and the disabilities due to injuries resulted from trauma. METHOD: Review of the literature using computerized database of National Library of Medicine and the International Institutes of Health MEDLINE using PubMed interface. There were selected the articles that address the issue of trauma registry from the different world trauma systems. RESULTS: Trauma registries have developed once they were introduced in centers and trauma systems in the United States of America in 1970. First trauma database processed on computers was created in 1969 in Cook County Hospital in Chicago. This database became the prototype of trauma registry in Illinois which started gathering information from 50 designated hospitals across the entire state in 1971.Countries with limited resources were able to start useful trauma registers. Continuous financing and dedicated personnel inside the team are two essential factors in the success of a trauma registry. NISS (New Injury Severity Score) higher than 15 is a widely used inclusion criteria in the trauma register. Exclusion is represented by patients admitted at over 24 hours after the accident, those declared dead before hospital arrival or with no signs of life on arrival in hospital. In addition, it is recommended that asphyxia,drowning and burns to be excluded. CONCLUSION: The improvements regarding the treatment of multi-traumatized people in developing countries depend on establishing and performance of trauma systems, where trauma registry represents a part of these systems infrastructure.

Prognostic scoring systems-validation and their utility in patients with abdominal sepsis in colon peritonitis.

AIM: The purpose of this article is to analyze and validate the CR-POSSUM score in patients with peritonitis of colonic origin, considering mortality forecasting ability. METHODS: We conducted a prospective longitudinal study of the Surgery Clinic in the Emergency Hospital in Bucharest in January 2008-December 2011. Patients operated on for peritonitis of colonic origin were included in this study. The prognostic CR-POSSUM scores and Mannheim peritonitis index were calculated by using data from observation sheets. There have been a number of deaths and overall mortality was calculated. RESULTS: There were 58 patients with abdominal sepsis, hospitalized and operated, registering a 17.24% mortality rate. Time from admission until the time of operation was divided between up to 24 hours and over 24 hours, recording 27 (46.55%) cases operated <24 hours and 31 (53, 45%) of patients operated> for 24 hours. Operative severity scores were calculated by taking into account data provided by each surgeon on intraoperative appearance. CONCLUSIONS: The results of this study demonstrated that both CR-POSSUM score and Mannheim have a prognostic value for patients with abdominal sepsis in colonic peritonitis, both being surgery scores.

Splenic implant assessment in trauma.

Trauma is a global health issue, being the 4th death cause after cardio-vascular disease, malignancies and chronic pulmonary diseases and the main death cause among young people, under 45 years (1). The frequency of abdominal trauma is 10-12% of all polytrauma, and from all abdominal organs, the spleen and liver are the most often involved in polytraumatized patients case (2). The first purpose of a successful operational management is the control of active bleeding, and the second is preserving as much as possible of the destroyed organs. Over the last decades, the treatment of spleen traumas had been diversified,from nonsurgical treatment to surgical, also complex and diversified: from conservative treatment to splenectomy.Currently, from a therapeutic standpoint, the trends in spleen trauma are orientated towards conservative methods as the clinical and experimental data have shown that €œit is better with the entire spleen than part of it, and better with a part of it than with none at all (Raymond Hinshaw) (3).

Involvement of reactive oxygen species in the mechanisms associated with cervical cancer specific treatment.

Cervical cancer represents a genuine health issue in Romania.The courses of treatment applied are complex, and the accompanying biochemical mechanisms are yet to be fully understood. Thus, radiotherapy, which induces reactive oxygen species, can lead to failure of treatment in hypoxic tissues,tissues which are difficult to identify due to the small quantity in which these cytotoxic species are produced. As a result, the aim of this paper is to identify the production and role of reactive oxygen species, as well as the manner of activation of endogenous antioxidant defense mechanisms in cervical cancer patients admitted to the Oncologic Institute of Bucharest. To this purpose the biochemical parameters of oxidative stress were identified in 30 patients with cervical tumour localization, prior to surgery. The results obtained have showed that a production of reactive oxygen species is identifiable in these patients, having lipids as a primary target and leading to their peroxidation. The extension of protein oxidative degradation takes place at a much lower value, as well as the activation of endogenous antioxidant defence systems, comparing to our expectations. To conclude,we consider that when the production of active oxygen metabolites takes place in small concentrations, associated with hypoxia, the signals transmitted are towards modifying the phenotype under anaerobic conditions into one activating neo vascularization, angiogenesis initiation, new cell growth and proliferation. The moment that this phase is overcome anew oxidative stress is installed, one potentially destructive for biomolecules essential to life, but also useful for further treatment, such as radiotherapy.

Current strategies in the therapeutic approach for adenocarcinoma of the ampulla of Vater.

INTRODUCTION: Ampulla of Vater tumors, neoplastic diseases located at the confluence of the common bile duct with the main pancreatic duct; represent 0.2% of all gastrointestinal cancers. METHOD: Retrospective study of all patients admitted in the Emergency Hospital of Bucharest Romania between January 2008 and January 2013, the only selection criterion used being a pathology report which describes an ampulla of Vater carcinoma. We have also performed a review of the medical literature up to 2013, using the PubMed/Medline, Proquest Hospital Collection, Science Direct, Cochrane Library and Web of Science databases. We have used different combinations of the following keywords: "ampulla of Vater", "carcinoma", "resection", reviewing the reference list of retrieved articles for further relevant studies. RESULTS: Forty eight patients with ampulla of Vater carcinoma were identified, of whom 59.6% men, 71% from urban areas, and a mean age of 66 ± 13.3 years. Most patients were admitted for obstructive jaundice (49%), right upper quadrant abdominal pain (19%), nausea and loss of appetite in 13%, loss of weight (13%) and upper digestive obstruction in 6% of cases. All patients were evaluated with abdominal transparietal ultrasonography and double contrast, pancreatic protocol, Mutidetector Row Computed Tomography. The abdominal Magnetic Resonance Imaging was performed in 10 cases, upper gastrointestinal endoscopy in 9 cases, and Endoscopic Retrograde Cholangiopancreatography in 39 cases. According to the AJCC Cancer Staging 9% were into stage I, 47% into stage II, 40% into stage III and 4% into stage IV of the disease. The therapeutic approach was surgical for 44 patients and an endoscopic palliation with stent insertion in 4 cases. The surgical procedure was represented by Whipple pancreatoduodenectomy in 27 cases, pylorus preserving pancreatoduodenectomy in 15 cases and exploratory laparotomy in 2 cases. Early morbidity was represented by pancreatic leakage in 4 cases. CONCLUSIONS: There are clinical scenarios in which it is quite challenging to distinguish a primary ampullary adenocarcinoma based on a preoperative workup. Nevertheless, an aggressive approach should be performed, knowing the higher resectability rates and a five-year survival for these patients. Complete surgical resection should be performed in all medically fit patients, candidates for pancreatoduodenectomy, by a high volume, trained surgeon, able to offer a low morbidity and mortality.

Traumatic colon injuries -- factors that influence surgical management.

BACKGROUND: This study sought to evaluate current trends in surgical management of colon injuries in a level I urban trauma centre, in the light of our increasing confidence in primary repair. METHODS: Our retrospective study evaluates the results of 116 patients with colon injuries operated at Bucharest Clinical Emergency Hospital, in the light of some of the most commonly cited factors which could influence the surgeon decision-making process towards primary repair or colostomy. RESULTS: Blunt injuries were more common than penetrating injuries (65% vs. 31%). Significant other injuries occurred in 85 (73%) patients. Primary repair was performed in 95 patients (82%). Fecal diversion was used in 21 patients(18%). Multiple factors influence the decision-making process: shock, fecal contamination, associated injuries and higher scores on the Abdominal Trauma Index (ATI) and Colon Injury Scale (CIS). Colon related intra-abdominal complications occurred in 7% of patients in whom the colon injury was closed primarily and in 14% of patients in whom a stoma was created, ATI having a predictive role in their occurrence. The overall mortality rate was 19%. CONCLUSIONS: Primary repair of colon injuries, either by primary suture or resection and anastomosis, is a safe method in the management of the majority of colonic injuries. Colostomy is preferred for patients with ATI ≥ 30 and CIS ≥ 4. Surgical judgment remains the final arbiter in decision making.

Laparoscopic treatment of perforated duodenal ulcer -- a multicenter study.

AIM: The aim of this study is to evaluate the results of the laparoscopic treatment of perforated duodenal ulcer performed in 6 Romanian surgical centres with experience in the field of laparoscopic surgery. MATERIAL AND METHOD: Between 1996 and 2005, 186 patients with perforated duodenal ulcer were operated on in the centers participating in this retrospective study, all patients being ASA I-II. Thirty-nine patients (20.0%) presented mild peritonitis, 120 (64.5%) medium peritonitis and 27 (15.5%) severe (20.0%) simple suture was performed, in 110 (59.1%) suture with epiplonoplasty, for 1 (0.5%) only epiplonoplasty and 1 (0.5%) underwent excision of the perforation and suture. RESULTS: The operative time was between 30-120 minutes, with an average of 75 minutes. No death was noted. Average hospitalization time was 6 days, with periods varying between 3 and 18 days. Postoperative complications included: 5 patients (2,6%) presented infections of the abdominal walls, 1 patient (0.5%) duodenal fistula, 1 patient (0.5%) intra-abdominal abscess, 1 patient (0.5%) a superior digestive hemorrhage by "mirrored ulcer" and 1 patient (0.5%) duodenal stenosis 6 months after operation. The patients were administered 50% less analgesics, used 70% less dressings, 30% less antibiotics and had 60% less complications in comparison with those operated by the classical approach. CONCLUSION: The laparoscopic approach of perforated duodenal ulcer constitutes the first choice for patients without important co-morbidities, allowing a quick recovery and a significant reduction in the consumption of analgesics, antibiotics and dressing materials.

A rare cause of acute massive lower gastrointestinal bleeding.

Even if lower gastrointestinal bleeding (LGIB) can present as trivial haematochezia, massive hemorrhage with shock may occur. Acute massive LGIB is defined as bleeding of recent duration that originates beyond the ligament of Treitz and encompasses: passage of a large volume of red or maroon blood through the rectum, haemodynamic instability and shock, initial decrease in haematocrit level of 6 g/dL or less, transfusion of at least 2 U of packed red blood cells, bleeding that continues for 3 days or significant rebleeding in 1 week. This report presents the case of a 58-year-old man with massive LGI bleeding. Colonoscopy was performed in emergency with a poor colonic preparation, but the examiner fortunately and with difficulty managed to identify the source of the haemorrhage- a Dieulafoy's lesion of the right colon. The bleeding was successfully stopped permanently by injecting sclerosing agents into the spurting vessel. We have preferred colonoscopy as our first choice of investigation due to the facile availability and the opportunity of endoscopic haemostasis in case of finding the source of bleeding. Angiography was planned in case of failure of the first method. The definition, clinical presentation, and treatment of Dieulafoy's lesion are further discussed.

Molecular characterization of Echinococcus granulosus in south-eastern Romania: evidence of G1-G3 and G6-G10 complexes in humans.

Clin Microbiol Infect ABSTRACT: Echinococcus granulosus is the aetiological agent of cystic echinococcosis (CE), which is a public health problem in many eastern European countries, particularly in Romania, where the infection causes a high number of human and animal cases. To shed light on the transmission patterns of the parasite, we performed a genotyping analysis on 60 cyst samples obtained from patients who live in south-eastern Romania and who underwent surgery for liver or lung CE. DNA was extracted from the endocysts or the cyst fluids, and fragments of cytochrome c oxidase subunit 1 and NADH dehydrogenase subunit 1 mitochondrial genes (cox1 and nd1, respectively) were amplified by PCR and sequenced. We found that most of the samples analysed (59/60) belonged to the G1-G3 complex (E. granulosus sensu stricto), which contains the most widespread and infective strains of the parasite. We also identified the first human patient infected by a non-G1-G3 genotype of E. granulosus in this country. As the DNA sequence of this cyst sample showed maximum homology with the G6-G10 complex (Echinococcus canadensis), this is, in all likelihood, a G7 genotype, which is often found in pigs and dogs in most countries of eastern and south-eastern Europe.